Tradeoffs in Vascular Access Selection in Elderly Patients Initiating Hemodialysis With a Catheter
Tradeoffs in Vascular Access Selection in Elderly Patients Initiating Hemodialysis With a Catheter
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DOI：
10.1053/j.ajkd.2018.03.023
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发表时间：
2018-10-01
影响因子：
13.2
通讯作者：
Allon, Michael
中科院分区：
文献类型：
--
作者：
Lee, Timmy;Qian, Joyce;Allon, Michael
理论与目的：国家血管通路指南建议在血液透析患者中放置动静脉瘘(AVF)而不是移植物(AVG)，但尚未在老年人中进行全面评估。我们评估了在血液透析治疗开始后接受AVF或AVG的老年患者的临床相关血管访问结果。研究设计：使用国家管理数据进行的回顾性队列研究。背景和参与者：来自美国肾脏数据系统的9,458名67岁及以上的美国患者的数据，这些患者在2010年7月1日至2011年6月30日期间使用导管开始血液透析治疗，并在随后的6个月内接受了AVF(n=7,433)或AVG(n=2,025)。预测因素：动-静脉通路亚型，AVF或AVG。结果：血管通路的成功使用，使血管通路功能发挥作用的干预措施，血管通路成功使用前的导管依赖时间，干预频率，血管通路成功使用前的导管依赖时间分析方法：用多元Logistic回归分析比较AVF和AVG成功使用前的干预需求，用负生物学回归分析计算成功使用血管通路后的干预频率。结果：AVF组在成功使用血管通路后6个月内不成功使用血管通路的比例高于AVG组(51%比45%；调整后的HR，1.86；95%CI，1.73-1.99)。动静脉瘘患者的血管通路功能干预比动静脉曲张患者多(42%比23%；OR，2.66；95%CI，2.26-3.12)。与AVGs相比，AVF在成功使用后1年的弃置率较低(OR，0.71；95%CI，0.62-0.83)，成功使用后需要的干预措施减少四分之一(相对风险，0.75；95%CI，0.69-0.81)。接受动静脉瘘的患者在成功使用之前对导管的依赖程度显著长于接受动静脉管的患者(中位时间，3个月比1个月；P<；0.001)。限制：由于血管通路的选择、对老年人群的限制以及一年的随访期，残留的混淆。结论：在开始使用导管的老年血液透析患者中，最佳的血管通路选择取决于较短的导管依赖性和较少的干预之间的权衡，以使血管通路在成功使用血管通路(AVF)后能够起作用，而较长的通路通畅率和较少的干预措施。
Rationale & Objective: National vascular access guidelines recommend placement of arteriovenous fistulas (AVFs) over grafts (AVGs) in hemodialysis patients, but have not been comprehensively assessed in the elderly. We evaluated clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation.Study Design: Retrospective cohort study using national administrative data.Settings & Partcipants: Claims data from the US Renal Data System of 9,458 US patients 67 years and older who initiated hemodialysis therapy from July 1, 2010, to June 30, 2011, with a catheter and received an AVF (n = 7,433) or AVG (n = 2,025) within the ensuing 6 months.Predictor: Arteriovenous access subtype, AVF or AVG.Outcomes: Successful use of vascular access, interventions to make vascular access functional, duration of catheter dependence before successful use of vascular access, frequency of interventions, and abandonment after successful use of vascular access.Analytical Approach: Multivariable logistic regression analysis was used to compare the need for intervention before successful use of AVFs and AVGs, and negative bionomial regression was used to calculate the frequency of intervention after successful use of vascular access.Results: Unsuccessful use of vascular access within 6 months of creation was higher for AVFs versus AVGs (51% vs 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99). Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs 23%; OR, 2.66; 95% CI, 2.26-3.12). AVFs had a lower 1-year abandonment rate after successful use compared with AVGs (OR, 0.71; 95% CI, 0.62-0.83) and required one-fourth fewer interventions after successful use (relative risk, 0.75; 95% CI, 0.69-0.81). Patients receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs 1 month; P < 0.001).Limitations: Residual confounding due to vascular access choice, restriction to an elderly population, and 1-year follow-up period.Conclusions: In elderly hemodialysis patients initiating hemodialysis therapy with a catheter, the optimal vascular access selection depends on tradeoffs between shorter catheter dependence and less frequent interventions to make the vascular access (AVG) functional versus longer access patency and fewer interventions after successful use of the vascular access (AVF).